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PAPERS: Anne Helene Olsen, Sisse H Njor, Ilse Vejborg, Walter Schwartz, Peter Dalgaard, Maj-Britt Jensen, Ulla Brix Tange, Mogens Blichert-Toft, Fritz Rank, Henning Mouridsen, and Elsebeth Lynge Breast cancer mortality in Copenhagen after introduction of mammography screening: cohort study BMJ 2005; 330: 220 [Abstract] [Full text]

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Benefits and harms of breast cancer screening

Peter C. Gøtzsche, Karsten J. Jørgensen, physician, Nordic Cochrane Centre, and Hazel Thornton, Honorary Visiting Fellow, Department of Health Sciences, University of Leicester.   (17 January 2005)

A screen always allows some particles to fall through and be washed away...

Dr. Herbert H. Nehrlich   (18 January 2005)

Is the drop in the breast cancer mortality in Copenhagen caused by mammography screening?

Per-Henrik Zahl, Professor Jan Mæhlen, Dept of pathology, Ullevål University Hospital, N-0407 Oslo, Norway   (19 January 2005)

Is the drop in the breast cancer mortality in Copenhagen caused by mammography screening?

Per-Henrik Zahl, Professor Jan Mæhlen, Ullevål University Hospital, Norway   (21 January 2005)

My Way in the War against Malignacy: the pivotal Role of Oncological Terrain.

Sergio Stagnaro   (28 January 2005)

Fall in HRT use would have reduced breast cancer mortality

Ellen C G Grant   (28 January 2005)

Re: Benefits and harms of breast cancer screening

Naseem Rashid, addressed to all   (29 January 2005)

Author's response

Elsebeth Lynge, Anne Helene Olsen   (24 February 2005)

Re: Author's response

Stevie M Gamble   (24 February 2005)

Is the drop in breast cancer mortality in Copenhagen caused by mammography screening?

Per-Henrik Zahl, Professor Jan Mæhlen   (3 March 2005)

Re: Author's response, Copenhagen mammography study

Stephen W. Duffy   (7 March 2005)

Breast cancer screening interests

Anders Beich   (30 March 2005)

Prospects of breast screening in UK

gargi sanyal   (9 May 2005)

Benefits and harms of breast cancer screening 17 January 2005
Peter C. Gøtzsche, Director The Nordic Cochrane Centre, Rigshospitalet Dept. 7112, Blegdamsvej 9, DK-2100 Copenhagen, Denmark, Karsten J. Jørgensen, physician, Nordic Cochrane Centre, and Hazel Thornton, Honorary Visiting Fellow, Department of Health Sciences, University of Leicester. Send response to journal: Re: Benefits and harms of breast cancer screening	The authors found a 25% reduction in breast cancer mortality in Copenhagen compared with what they would expect to find in the absence of screening (1). Their result is based on an observational study; this method is not considered to be a reliable design for evaluating mortality reductions with screening (2). The full mortality reduction was seen after only 3 years of follow up, where it was nearly statistically significant, and it stayed at that level for the next 7 years. However, both randomised trials and cohort studies have clearly shown that a positive effect of screening does not come that quickly. It therefore seems likely that the study has provided an exaggerated mortality benefit. The authors have not declared any conflicts of interest. However, two of them are heads of screening units, and the attendance rate in Copenhagen has dropped to 63% (3) which is well below the minimum acceptable level of 70% and the desirable level of 75% required for a screening program (4). This conflict of interest could potentially influence the authors’ interpretation of the data, particularly regarding harms. The authors did not provide data on harms but refer to another study (5) when they claim that the introduction of mammography screening in Copenhagen did not lead to an increase in breast cancer incidence apart for the expected prevalence peak. Their conclusion in that study is even stronger since they say that mammography screening can operate without overdiagnosis (5). As discussed elsewhere (6), their data do not support this conclusion, and much larger studies, both randomised and nonrandomised, have shown that the level of overdiagnosis is about 30%, or even more (7-9). Proper evaluation of findings about any medical intervention requires that balanced and unbiased presentation of benefits and harms are stated. We therefore believe that positive effects of screening should never be presented without corresponding data on the major harms. The harms in this case are considerable. Based on the randomised trials, it can be calculated that for every 1000 women who are invited for screening throughout 10 years, most optimistically one (corresponding to a 30% reduction in breast cancer mortality) will have her life prolonged (10) while at least 5 healthy women (corresponding to 30% overdiagnosis) will be converted into cancer patients unnecessarily because of overdiagnosis (7). Added to this, about 200 of these women will get a false positive diagnosis during ten biennial screens (11). It is not trivial that about 20% of the screened female population will get such a message since many of them will interpret it as if they are going to die from cancer. These harms, and the small benefit, are what make mammography screening so controversial. 1. Olsen AH, Njor SH, Vejborg I, Schwartz W, Dalgaard P, Jensen M-B, et al. Breast cancer mortality in Copenhagen after introduction of mammography screening: cohort study. BMJ, doi:10.1136/bmj.38313.639236.82 (published 13 January 2005). 2. Vainio H, Bianchini Fe. IARC Handbooks of Cancer Prevention. Volume 7. Breast Cancer Screening. Lyon: IARC Press, 2002. 3. Methling I. Færre undersøges for brystkræft. Politiken 2005; 13. januar, 1. sektion, s. 5. 4. European guidelines for quality assurance in mammography screening. Luxemburg: Office for Official Publications of the European Communities. Third edition, 2001. 5. Olsen AH, Jensen A, Njor SH, Villadsen E, Schwartz W, Vejborg I, et al. Breast cancer incidence after the start of mammography screening in Denmark. Br J Cancer 2003; 88(3):362-5. 6. Zahl P-H. Overdiagnosis of breast cancer in Denmark. Br J Cancer 2004;90:1686. 7. Gøtzsche PC. On the benefits and harms of screening for breast cancer. Int J Epidemiol 2004;33:56-64. 8. Douek. M, Baum M. Mass breast screening: is there a hidden cost? Br J Surg 2003; 90 suppl 1:June (Abstract Breast 14). 9. Zahl PH, Strand BH, Maehlen J. Incidence of breast cancer in Norway and Sweden during introduction of nationwide screening: prospective cohort study. BMJ 2004; 328(7445):921-4. 10. Nyström L, Rutqvist LE, Wall S, Lindgren A, Lindqvist M, Ryden S, et al. Breast cancer screening with mammography: overview of Swedish randomised trials. Lancet 1993;341:973–78. 11. Hofvind S, Thoresen S, Tretli S. The cumulative risk of a false- positive recall in the Norwegian Breast Cancer Screening Program. Cancer 2004;101:1501-7. Competing interests: PCG was involved in a systematic review that questioned the value of screening.
A screen always allows some particles to fall through and be washed away... 18 January 2005
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507 Send response to journal: Re: A screen always allows some particles to fall through and be washed away...	How uplifting, how very refreshing! These comments can serve to restore some faith in our once wonderful and honest profession. I would have loved to be able to thank the authors personally but there is that idiotic problem about hiding individuals' e-mail addresses. Screening is apparently viewed by very large portions of western populations as a necessary, even essential tool, designed to save lives. People are being brainwashed and have finally accepted the fact that these things (like charities) need to be run like businesses. Profitable businesses. Like the widespread use of what I call the "confusion technique", where figures are tossed around to persuade people to submit to (often free) screening, more and more new ways of marketing are found , to "save lives". And who out there among the guinea pigs would know the difference between absolute risk and relative risk?! Who will join me in hanging my head in shame ? Competing interests: None declared
Is the drop in the breast cancer mortality in Copenhagen caused by mammography screening? 19 January 2005
Per-Henrik Zahl, Senior Statistician Norwegian Institute of Public Health, PO Box 4404, N-0403 Oslo, Norway, Professor Jan Mæhlen, Dept of pathology, Ullevål University Hospital, N-0407 Oslo, Norway Send response to journal: Re: Is the drop in the breast cancer mortality in Copenhagen caused by mammography screening?	Letter to BMJ, Olsen et al [1] reported that the breast cancer mortality in Copenhagen for the age group 50-74 years dropped by 20% to the same level as in the rest of Denmark, and related this drop to mammography screening. But other explanations are more likely since a 22% (p-value = 0.01) reduction in breast cancer mortality in Copenhagen has also occurred in the non-invited age group 40-54 years (almost all breast cancer deaths in the age group 50-54 years are cases diagnosed before age 50). In the period 1981-90, 201 breast cancer deaths occurred in Copenhagen in the age group 40-54 years and 177 deaths occurred in the period 1991-2000. The number of exposure years increased from about 340 000 to about 385 000. During the last 20 years there has been a large increase in non- Western residents in Copenhagen. It is also possible that a reduction in the relative number of nulliparous women has occurred. We therefore propose that most of the 20% reduction in breast cancer mortality in Copenhagen is caused by a relative increase in the fertility quotient, and other non-screening related factors including tamoxifen treatment. 1. Olsen AH, Njor SH, Vejborg I, Schwartz W, Dalgaard P, Jensen M-B, et al. Breast cancer mortality in Copenhagen after introduction of mammography screening: cohort study. BMJ, doi:10.1136/bmj.38313.639236.82 (published 13 January 2005). Competing interests: None declared
Is the drop in the breast cancer mortality in Copenhagen caused by mammography screening? 21 January 2005
Per-Henrik Zahl, Senior Statistician Norwegian Institute of Public Health, PO Box 4404 Nydalen, N-0403 Norway, Professor Jan Mæhlen, Ullevål University Hospital, Norway Send response to journal: Re: Is the drop in the breast cancer mortality in Copenhagen caused by mammography screening?	Letter to BMJ, Is the drop in the breast cancer mortality in Copenhagen caused by mammography screening? Olsen et al [1] reported that the breast cancer mortality in Copenhagen for the age group 50-74 years dropped by 20% when they compared the mortality in the screening period (1991-2001) with that in a prescreening period (1981-1991), and they considered this decrease was caused by screening. However, according to Statistics Denmark, 201 breast cancer deaths occurred in Copenhagen in the age group 40-54 years in the period 1981-90 and 177 deaths occurred in the period 1991-2000. The number of exposure years increased from about 340 000 to about 385 000. Calculating mortality rates based on years of exposure, we find a 22% decrease in the age group 40-54 in Copenhagen (P = 0.015). Most of these women (those below 50 years of age) have not been invited to screening. And almost all of deaths in the age group 50-54 years were from cancers that were diagnosed before age 50. Hence, the decrease in breast cancer mortality the authors observed in the screened age groups cannot be ascribed to an effect of screening, but must be ascribed to other factors. During the last 20 years there has been a large increase in non- Western residents in Copenhagen. It is also possible that a reduction in the relative number of nulliparous women has occurred. We therefore propose that the 20% reduction in breast cancer mortality in Copenhagen is caused by a relative increase in the fertility quotient, and other non- screening related factors, including tamoxifen treatment. 1. Olsen AH, Njor SH, Vejborg I, Schwartz W, Dalgaard P, Jensen M-B, et al. Breast cancer mortality in Copenhagen after introduction of mammography screening: cohort study. BMJ, doi:10.1136/bmj.38313.639236.82 (published 13 January 2005). Competing interests: None declared
My Way in the War against Malignacy: the pivotal Role of Oncological Terrain. 28 January 2005
Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseaes. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8. 16037 RivaTrigoso (Genova) Italy. Send response to journal: Re: My Way in the War against Malignacy: the pivotal Role of Oncological Terrain.	Sirs, The authors of this controversial paper evaluated the effect on breast cancer mortality during the first 10 years of the mammography service screening programme in Copenhagen, Denmark, exclusively in females. What happened thereafter to some (those screened), but not all the female Danish population? I mean that also males, although rarely, can be affected by breast cancer; if in the Copenhagen programme breast cancer mortality was reduced without severe negative side effects for the participants, the benefit did not include either males or the entire female population. In addition, for example, I’d like to remember a recent paper data in certain disagreement with those of the authors: “No reduction in breast cancer mortality was seen in women aged 20-39 years” (2), who underwent mammography, of course. In addition, I cannot agree with all authors, who state accordingly that mammographic screening nowadays is well established. In fact, all around the world authors ignore or overlook the existence of Oncological Terrain (See HONCode site 233736, www.semeioticabiofisica.it) as well as bed-side recognizing breast cancer “real risk”, in a quantitative way (2,3,4), according to my theory of Single Patient Based Medicine (5), suggested also by European Authorithy in Cancer Prevention (“Planning for the EU public Health Portal” all’URL:http://www.google.it/search?q=cache:U5A- DtWmRDsJ:europa.eu.int/comm/health/ph_information/documents /ev_20030710_co01_en.pdf+single+patient+based+medicine+and+ stagnaro&hl=it&ie=UTF-8 Pg 36). Consequently, all authors think "wrongly" that “all” women – but not men (!) – must urdergo mammography and other screening measures, therefore spending uselessly NHS money, and physician’s energy and time. Importantly, screening is not at all the same as PRIMARY prevention! As a matter of fact, a “really” healthy woman can be affected by Oncological Terrain, even with or without precise location in a well defined breast quadrant (“ab posse ad esse non licet illatio”, Kant, Kritik der reinen Vernunft) (5). I think that because the congenital functional mitochondrial cytopathology I described 25 years ago is overlooked (3-6) - "conditio sine qua non" of the most frequent and dangerous human disorders, including malignancies - all current clinical research is fundamentally biased (See my open letter to italian Ministro della Salute about Breast Cancer Biophysical-Semeiotic Primary Prevention: http://www.katamed.it/Notizia.asp? id=8094&lingua=IT&idcat=999; http://xoomer.virgilio.it/piazzetta/professione/professione.htm; http://www.ilpungolo.com/site/leggi.asp?NWS=2390&IDS=10 ; http://bmj.bmjjournals.com/cgi/eletters?lookup=by_date&days=1#72216 27 August 2004 . In a few words, competent authority (except that mentioned above, of course) does not consider the existence or assess the seriousness as well as the location of Congenital Acidosic Enzyme-Metabolic Histangiopathy (3-6), conditio sine qua non also of Oncological Terrain. In fact, both environmental risk factors and every drug, including oestrogens (at least in some women), suggested as a risk factor for breast cancer, "could" influence some human biological functions and/or bring about different disorders, such as cancers, exclusively in relation to both the presence and intensity of CAEMH, particularly in a well-defined biological system. For instance, despite the well-known negative influence of oral contraceptive use on breast oncogenesis (1-5) and/or arterial disorders we have to consider the importance of the “genetic predispositions” , as far as the onset of a lot of disorders is concerned, including breast cancer (See my above-cited site). In conclusion, we need at first (i.e., starting whatever primary prevention, screening or research on malignancy) to investigate the presence and intensity of CAEMH in the "tested" population, i.e. in "every single" patient, and soon thereafter assessing presence, intensity of the "Oncological Terrain" and finally the precise location of “real risk” of cancer, which always develops on the basis of the above-mentioned congenital mitochondrial cytopathology and its consequences, as Oncological Terrain. In fact, without this alteration of psycho-neuro-endocrine-immunological system, oncogenesis is not possible, as allows me to state a 46-year-long clinical experience with Biophysical Semeiotics, Single Patient Based Medicine theory is based on (6). The importance of the above-mentioned congenital constitution (i.e. predisposition to malignancy, both solid and liquid) should not be overlooked, particularly when we assess a "possible" risk factor for cancer and then for cancer primary prevention, which is well different from screening. 1) Olsen A H., et al. Breast cancer mortality in Copenhagen after introduction of mammography screening: cohort study BMJ 2005;330:220 (29 January), doi:10.1136/bmj.38313.639236.82 (published 13 January 2005) 2) Mayor S. Mammography screening nearly halves breast cancer mortality BMJ 2003;326:949 ( 3 May ) 3) Stagnaro-Neri M., Stagnaro S., Cancro della mammella: prevenzione primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. – Arch. Sc. Med. 152, 447, 1993. 4) Stagnaro Sergio, Stagnaro-Neri Marina. Introduzione alla Semeiotica Biofisica. Il Terreno oncologico”. Travel Factory SRL., Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm. 5) Stagnaro S., Istangiopatia Congenita Acidosica Enzimo-Metabolica. Una Patologia Mitocondriale Ignorata. Gazz Med. It. – Arch. Sci. Med. 144, 423, 1985 (Infotrieve) 6) Stagnaro S., Stagnaro-Neri M., Single Patient Based Medicine.La Medicina Basata sul Singolo Paziente: Nuove Indicazioni della Melatonina. Travel Factory SRL., Roma, 2004 Competing interests: None declared
Fall in HRT use would have reduced breast cancer mortality 28 January 2005
Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU,UK Send response to journal: Re: Fall in HRT use would have reduced breast cancer mortality	The fall in breast cancer deaths in women aged 40 to 54, first diagnosed under age 50 during 1991-2000, but not invited for screening, could be due to the reduction in OC and HRT use following warnings of increased risk of thrombosis.1 In 1995-6, several large studies confirmed an increased risk of primary thrombosis of 4 – 6 times with different progestogen/oestrogen combinations.2 Use of “third” generation progestogens, desogestrel, gestodene and norgestimate, which had double the risk of thrombosis compared with “second” generation progestogens, sharply declined after warnings of increased risks. Less than 12 months use of most HRT formulations increased breast cancer risk; quantified at 45-63 per cent in the Million Women Study (MWS), which also found current use of HRT doubled the risk of breast cancer and increased breast cancer fatalities by at least 22 per cent. In both the MWS and the US Women’s Health Initiative (WHI) studies progesterone HRT caused 4 times more breast cancer than oestrogen-only HRT. 10 years of progesterone or oestrogen HRT increased risks 3 times more breast cancer than 5 years of use. HRT increases breast growth and vascularity making these cancers particularly difficult to diagnose by mammography. Changes in hormone use have played a large part in breast cancer mortality incidence changes and should not be ignored in studies of the effect of treatments.5,6 1 Zahl P-H., Maehlen J. Is the drop in the breast cancer mortality in Copenhagen caused by mammography screening? http://bmj.com/cgi/eletters/330/7485/220#93479, 20 Jan 2005 2 Grant ECG. Thrombosis and heart attacks with contraceptive and menopausal hormones. J Nutr Environ Med. 1998; 8: 159-67. 3 Beral V, Banks E, Reeves G, Bull D, on behalf of the Million Women Study Collaborators. Breast cancer and hormone-replacement therapy: the Million Women Study. Lancet 2003; 362: 1331. 4 Chlebowski RT, Hendrix SL, Langer RD, et al, for the WHI Investigators. Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women’s Health Initiative randomised trial. JAMA 2003: 289: 3243-53. 5 Grant ECG. Increases in breast cancer incidence http://bmj.com/cgi/eletters/328/7445/921#55298, 1 Apr 2004 6 Grant ECG. Re: Rapid Responses; Authors' reply. http://bmj.com/cgi/eletters/328/7445/921#55843, 6 Apr 2004 Competing interests: None declared
Re: Benefits and harms of breast cancer screening 29 January 2005
Naseem Rashid, OB/GYN Consultant &MPH (MCH) Student GWU, Intern at Office of Disability, HHS, DC VA 20007, addressed to all Send response to journal: Re: Re: Benefits and harms of breast cancer screening	Can any one of the authors get or guide me to information on Breast Cancer Screening programs on women with disability, for examples with scoliosis, or on wheel chair, in fact any disability or physical deformaties that can made BSE and mamagraphy difficult to perform? I am looking for materials to address this matter. Competing interests: None declared
Author's response 24 February 2005
Elsebeth Lynge, Professor Department of Epidemiology, University of Copenhagen, Anne Helene Olsen Send response to journal: Re: Author's response	Unfortunately, Zahl and Mæhlen have misunderstood the design of our study (1), which is essential for the correct interpretation of the data. Our analysis is not a simple comparison of breast cancer mortality rates in Copenhagen before and after introduction of screening, but it also uses the data from the rest of Denmark outside the screening regions to adjust for the underlying time trend in breast cancer mortality. Using a similar model for the breast cancer mortality in women aged 40-49 in Copenhagen in the screening period gives a RR 0.94 (95% confidence interval 0.69-1.27). Women aged 40-49 in Copenhagen did therefore not experience the same reduction in breast cancer mortality as found for women aged 50-69. Gøtzsche et al try to miscredit our study by use of insinuations, a debate we will not waste time on. Readers interested in incidence of breast cancer following the introduction of screening are referred to our original paper (2). 1) Olsen AH, Njor SH, Vejborg I, Schwartz W, Dalgaard P, Jensen MB, et al. Breast cancer mortality in Copenhagen after introduction of mammography screening: cohort study. BMJ 2005; 330: 220-2. 2) Olsen AH, Jensen A, Njor SH, Villadsen E, Schwartz W, Vejborg I, et al. Breast cancer incidence after the start of mammography screening in Denmark. Br J Cancer 2003; 88: 362-5. Competing interests: None declared
Re: Author's response 24 February 2005
Stevie M Gamble, retired HMIT EC2Y 8BL Send response to journal: Re: Re: Author's response	Elsebeth Lynge and Anne Helene Olsen in their Rapid Response of 24/02/2005 assert that: ‘Gøtzsche et al try to miscredit our study by use of insinuations’ This is untrue. What Gøtzsche et al in their Rapid Response of 17/01/2005 actually said was: ‘The authors have not declared any conflicts of interest. However, two of them are heads of screening units, and the attendance rate in Copenhagen has dropped to 63% (3) which is well below the minimum acceptable level of 70% and the desirable level of 75% required for a screening program (4). This conflict of interest could potentially influence the authors’ interpretation of the data, particularly regarding harms.’ This is not an insinuation, it is a statement of fact. Stevie M Gamble Competing interests: None declared
Is the drop in breast cancer mortality in Copenhagen caused by mammography screening? 3 March 2005
Per-Henrik Zahl, Senior Statistician Norwegian Institute of Public Health, PO Box 4404 Nydalen, N-0403 Oslo, Norway, Professor Jan Mæhlen Send response to journal: Re: Is the drop in breast cancer mortality in Copenhagen caused by mammography screening?	In their Rapid Response of 24/02/2005 Lynge and Olsen assert that we misunderstood the design of their study (1). However, our comment was on the data set on which the study is based and not on the study design. From the period 1981-1991 to the period 1991-2001 Statistics Denmark recorded a 20% drop in breast cancer mortality both in the invited age group 50-69 years and in the un-invited age group 40-49 years. This important fact was omitted by Olsen et al (1). 1) Olsen AH, Njor SH, Vejborg I, Schwartz W, Dalgaard P, Jensen MB, et al. Breast cancer mortality in Copenhagen after introduction of mammography screening: cohort study. BMJ 2005; 330: 220-2 Competing interests: None declared
Re: Author's response, Copenhagen mammography study 7 March 2005
Stephen W. Duffy, Professor of Cancer Screening CR-UK Centre for Epidemiology, Mathematics and Statistics, Charterhouse Square, London EC1M 6BQ Send response to journal: Re: Re: Author's response, Copenhagen mammography study	With respect to criticisms of the Copenhagen mammogrpahy study, Dr Lynge's response is measured and correct. With its control for temporal and spatial effects, the Copenhagen study is a model of rigorous evaluation and honest interpretation. Those who believe that the breast cancer mortality reduction observed is due to other factors, have to explain why it did not occur in areas not served by the mammography programme. The have not convincingly done so. Accusations of conflict of interest represent a failure to engage with the scientific issues and are in any case unworthy of debate in the BMJ. It is high time this discussion grew up. Competing interests: None declared
Breast cancer screening interests 30 March 2005
Anders Beich, Research Fellow Research Unit of General Practice Copenhagen, University of CPH, PO Box 2099, DK-1014 Copenhagen K Send response to journal: Re: Breast cancer screening interests	Editor, This controversy somehow demonstrates how difficult it is to obtain a fundament for ”evidence-based prevention” free of competing interests. Professors in epidemiology, senior statisticians and screening professors that are somehow jammed in their cocksureness, bashing one another with numbers while their real disagreement seems to be one of value judgments. No wonder the population wonders, because they do it in the public press as well. If judged by these rapid responses, the question of competing interests raised by Gøtzsche seems to be highly relevant here (he even practices what he preaches and states one in his reply), and maybe such declarations should cover interests like reputation and prestige. Although we want knowledge and attitude to go before behaviour, we all have a tendency to become what we do and defend ourselves tooth and nail, especially if met by criticism of a life's work, the things some even hope to be remembered for. I was a co-author on a paper on screening based prevention (1) and I regret having contributed to the decline of respectful debate that took place here in the rapid responses afterwards. I do however support the view that it is unfortunate when screening programmes are evaluated by the same persons who run the programmes and are responsible for keeping the attendance rate high enough to continue the programme. As a physician, I have in the past attended meetings on mammography in the past where one of the authors made presentations on the bliss of breast cancer screening in a way that would make Scientologists and used car salesmen green with envy. It does not raise the credibility of the paper in my mind that he is now evaluating breast cancer screening in Denmark, and I am in no way trying to insinuate anything by saying that, just trying to illustrate the point. Anders Beich 1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-540. Competing interests: I have published papers that in a critical way have tried to assess the effectiveness and suitability of health behaviour screening in PHC.
Prospects of breast screening in UK 9 May 2005
gargi sanyal, SHO Medicine Princess Alexandra Hospital Harlow , CM20 1JL Send response to journal: Re: Prospects of breast screening in UK	Early detection of breast cancer is a promising approach to the lowering of mortality.In UK half a million is screened in the age group of 50-64, though the percentage in the younger group is alarming. 25 percent reduction in mortality by 2010 is quite a feat.The active implementation of Forrest report in 1980 led to achievement of the National average by 1990. The National Cancer plan which amalgamates the breast screning leads to the extension to upto age of 70 years.NHS Breast Screening Programme shows that it helped 300 women a year ,however the figures rise to four times in the early next decade. The effectiveness of NHS Screening Programme depends on active detection centre,quality of mammogram and treatment. The soaring incidence in less than 50 year old should be of concern and should be thought of. With a vision in mind there should be developement of resourced database followed by innovative technique in imaging and histopathology to assist with detection and diagnosis of breast malignancy. Dr Gargi Sanyal Competing interests: None declared